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GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED El AUGERS 0 HOSE 0 PIPE <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />I hereby certify that I am autho zed to complete this application and that the <br />San Jo t Ordinance Codes and Standards, and all other a <br />rk will be done in accordance with <br />licable California laws. <br />Title/Company STAFF GE OGIST / AGE <br />DEPARTMENT USE ONLY <br />Signed <br />Print Name Date 6/13/18 <br />Date Issued: <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />DES UCTION METHOD: (CHECK ALL THAT APPLY) <br />D OVE -ORE DIAMETER of inches to depth of feet <br />0 PRESSU GROUT To depth of feet below surface <br />0 EXPLOSIVE From to feet below surface <br />El MUSHROOM C 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: ** See work plan ** <br />./.6p.ouiN s N Byrn . <br />Ate76,'' COUNTY— <br />\\oafs:ex- ,1 <br />Greatness grows here -1.t/Foae1 <br />Environmen....i Health Department <br />RECEIVED <br />JUN 13 2018 <br />For Wells and Borings Used for Contaminant Investigations and Remediatk yIRONME <br />SITE MITIGATION WELL & BORING PERMIT APPLICATIOq <br />' <br />N <br />PERMIT/SERVICES <br />-TAL HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />48 Hours Advance Notice Required For All Inspections <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. , <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Job Address 540 North Hunter Street <br />Cross Street East Oak Street <br />City/State/Zip Stockton, California <br />Phone <br />APN 139-060-280 <br />(209) 467-1006 <br />Property Owner* Juen Lee <br /> <br />Phone (209) 467-1006 <br /> <br />Address 11699 Birchville Road City/State/Zip Nevada City, Califo ia <br />C-57 Contractor VANCED GEOENVIRONMENTAL, INC (AGE) License# 680227 Phone (209) 467-1006 <br />Address 837 SH <br /> <br />ROAD <br />City/State/Zip STOCKTON, A 95215 <br />Consultant/Sub-Contractor <br />Address 837 SHAW ROAD <br />License# 680227 Phone (209) 467-1006 <br />City/State/Zip STOC ON, CA 95215 <br />CONSTRUCTION WORK TO BE PER RMED: *Note: Offsite Borings/Wells Require Acce Agreements or Encroachment Permits <br /> <br />TYPE OF WELLJBORING <br />MONITORING <br />0 EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />[2:1 SOIL BORING <br />INJECTION (Air Spam. Ozone). <br />OTHER <br />NUMBER INSTALLATN TYPE CONSTRUCTION SPECIFICATIONS <br /> ID HOLLOW STEM BORING DEPTH 25' <br /> 0 HAMMER/DRIVEN DIA. OF BOREHOLE 1.25" <br /> o MUD ROTARY • SING THICKNESS <br />7 PUSH POINT (GP/ CPT) CO CTOR CASING <br /> 0 HAND AUGER GROUT AL DEPTH <br />0 OTHER: GROUT SEA UMPED? <br />BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> <br />Y- i No Boring Dia: Casing Dia: Casing Depth: <br />2 ' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE lI PIPE <br />Yes IS] No (Note: Maximum Freefall Depth is 30 Ft) <br />PORTLAND TYPE It WELL/ SOIL BORING IDs R-1 B-2 B-3 B-4, B-5 B-6 & B-7 GROUT SPECIE • Tb <br /> <br />FA Name FA Address FA# <br /> <br />FA PE ,4-' S.-9 WP Reviewed By L... .-x, Work Plan Date (o / i <br />1:1 C-57 0 C-57 uthorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval"ç MFR <br />COMMENTS/CON TIONS: <br />\ <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit $152x <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 io L tsti Wciell_Putermit4iApplication <br />3-0 03 s-1-5